Though so-called “dual relationships” are typically frowned upon by the mental health community, most therapy clients require a close, trusted friend almost as much as they do a therapist. So how can such a professional—ethically and practically—function simultaneously in both roles?
In general, clients need to feel genuinely cared about by their therapist. And so at times a therapist is called upon to concretely demonstrate that the relationship—though not exactly personal and requiring certain constraints—is not simply a business transaction. Which is paradoxical, since on one level it is a business relationship. After all, therapists' livelihoods depend on assessing a fee for their services. Consequently, they serve their clients at the same time that, reciprocally, their clients serve them, by paying for the “privilege” of such services.
Research has repeatedly shown that the single most curative factor in therapy isn’t simply the technique employed, or the therapeutic approach (from psychoanalytic, to cognitive-behavioral, to humanistic), but the relationship between client and therapist that develops during the course of treatment. Whether, deep down, the therapist is providing a corrective parenting experience, an unprecedented emotional release and resolution, or (somewhat more narrowly) the knowledge or skills requisite to the change requested by the client, ultimately it’s the relationship that principally determines the success of this unique professional engagement.
So how then do therapists best meet the requirements of becoming their client’s “professional friend”? How can they appropriately include—in what must be defined as a “working relationship”—the key elements of empathy, understanding, guidance, trust, and respect that will facilitate the essential change their clients seek?
Such therapy mandates are best met through flexibly, or open-mindedly, “tweaking” various professional rules and regulations. For example, it might be a simple matter of therapists' getting comfortable with clients’ occasionally sending them e-mails when they’re anxious to share something before their next session. Or when they’re feeling almost desperate to get some therapeutic input on some momentary crisis.
As long as therapists makes clear, at the outset, that such e-mails can’t become everyday occurrences and that their replies to client comments and questions will necessarily be brief, then allowing for such a benign “boundary expansion” should not put them under any undue pressure—or bend out of shape a relationship that must remain professional. Therapists would, of course, be within their rights to charge clients for this additional expenditure of time. But acting attorney-like in such situations will hardly give clients the message that their therapist has a sincere interest in their welfare independent of the fees earned by treating them.
The same might be said about between-session phone calls or, in rare cases of emotional emergency, extending the length of a client’s session. All clients want and, to whatever extent, need to be seen as “special.” And (if truth be told) just about everybody, however secretly, desires to be so perceived. Professionally, therefore, the key question is whether in selectively making exceptions for this or that client the therapist is cultivating unreasonable expectations in them that will likely be disappointed later—thus prompting the client to feel disgruntled, deceived, or even betrayed. Additionally, the therapist must explore whether inadvertently encouraging certain clients to feel “entitled” (and so strengthening their narcissistic tendencies) will only contribute to their frustrated disillusionment and discontent when others in their life, not seeing them as particularly special, are hardly inclined to follow suit.
Effective therapy relationships also involve therapists’ showing clients the “unconditional positive regard” that the humanistic/client-centered psychologist Carl Rogers popularized over a half-century ago. Affirming the client’s inherent worth and goodness regardless of how commendable their specific behaviors may have been, Rogers proclaimed the centrality of what might be called the therapist’s “professionally befriending” their client.
One way to translate this therapeutic dictum of regularly perceiving clients in a positive light is for therapists to look for opportunities to compliment their clients—or otherwise acknowledge them when, say, they notice that they’ve advantageously changed their hair style, or are wearing an outfit particularly flattering to them; or when they’re beginning to appear less anxious, depressed, angry, or stressed out; or when they’ve come up with a new insight, admirably integrating for themselves what they’ve been conscientiously working on.
Think about it. If the various goals of therapy are to be accomplished, the client must feel sufficient support and security in the relationship to feel truly safe. That is, safe enough to lower their defenses and tolerate increased levels of anxiety as they face difficult personal issues that, till now, they’ve felt compelled to avoid. Able to see their therapist not just in terms of clinical expertise but as someone genuinely concerned about their welfare is crucial if they’re to take the personal, and interpersonal, risks required for the change that—despite any fear-fueled ambivalence—they deeply desire.
It may seem ironic but therapists, even as they’re exhibiting sincere feelings of friendship (or humanistic regard) for their clients, must generally adhere to their profession’s code of ethics in establishing appropriate boundaries for them. Sympathetic, warmhearted feelings for their clients notwithstanding, their behavior, judgment, and decision-making must all be rooted in their assessment of what—immediately and ultimately—best serves the client’s needs. And at times what the client desires and what the therapist deems most advisable may diverge significantly. So, for example, while most therapists would rather not be contentious with their clients, at times such uncomfortable encounters may be critical if therapy is to be effective. Which is one reason that the oxymoron “supportive confrontation” so aptly describes this essential dimension of the therapeutic enterprise.
And here is one fundamental way that a professional relationship differs from a close friendship. The focus must always be on what will increase the possibility that the client will accomplish their chosen objectives. Interventions, therefore—as cordial, warm, and friendly as they may be—must be dictated by this cardinal, goal-oriented consideration. That is, the therapist needs to be a particular kind of close friend: one willing to communicate to the client things that, though they’re in the client’s best interests, may not at all reflect what he or she wants to hear.
Examples of this might include a therapist’s telling a client complaining about their social life that they emit a really bad body odor. For to refrain from sharing this would hardly help the client—though such an intervention would probably be uncomfortable for both parties. Or, in another instance, a therapist might be called upon to give the client critical feedback on their having approached a marital conflict in a manner almost guaranteed to elicit a strong, negative reaction from their spouse.
To conclude, it’s a tricky (and sometimes convoluted) path that therapists must follow if they’re to function in a role that no one else in the client’s life would likely choose—or, frankly, be qualified for. To be genuinely the client’s “professional friend” (and is that not a curious oxymoron?!), the therapist must be ready to soothe, support, and validate them, at the same time they take every opportunity to—therapeutically—challenge or confront them.
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© 2013 Leon F. Seltzer, Ph.D. All Rights Reserved.